Provider Demographics
NPI:1407981046
Name:BROWN, REGINA (PTA)
Entity Type:Individual
Prefix:MRS
First Name:REGINA
Middle Name:
Last Name:BROWN
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:374 E. GRAND AVE.
Mailing Address - Street 2:SIUC STUDENT HEALTH CENTER
Mailing Address - City:CARBONDALE
Mailing Address - State:IL
Mailing Address - Zip Code:62901
Mailing Address - Country:US
Mailing Address - Phone:618-453-6140
Mailing Address - Fax:618-453-4290
Practice Address - Street 1:374 E. GRAND AVE.
Practice Address - Street 2:SIUC STUDENT HEALTH CENTER
Practice Address - City:CARBONDALE
Practice Address - State:IL
Practice Address - Zip Code:62901
Practice Address - Country:US
Practice Address - Phone:618-453-6140
Practice Address - Fax:618-453-4290
Is Sole Proprietor?:No
Enumeration Date:2007-02-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant